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Re: Salvage Surgery after Energy Ablation for Renal Masses
LAPAROSCOPY/NEW TECHNOLOGY
332
Re: Impact of Warm versus Cold Ischemia on Renal Function following Partial Nephrectomy S. E. Eggener, M. A. Clark, S. Shikanov, B. Smith, M. Kaag, P. Russo, J. C. Wheat, J. S. Wolf, Jr., S. F. Matin, W. C. Huang, M. Harel, J. Cambio, A. L. Shalhav and J. D. Raman Section of Urology, University of Chicago, Chicago, Illinois World J Urol 2015; 33: 351e357.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.05.020 available at http://jurology.com/ Editorial Comment: This large multicenter study explores percent changes in estimated glomerular filtration rate in patients with a normal contralateral kidney treated with partial nephrectomy under warm (WI) or cold ischemia (CI). Because of the retrospective nature, differences between ischemia type groups were seen in baseline comorbidity, tumor size and renal function, reflecting intuitive surgeon choice. The second detail that captures attention is the higher percentage of CI cases in the whole population (63%) and in the open PN group (92%), likely reflecting practice at United States tertiary centers and the difficulties of applying CI during laparoscopic or robotic procedures. Lastly, albeit significantly, a discrete difference was observed in median ischemia time between groups. At long-term followup (3 to 18 months) neither WI nor CI time was significantly associated with estimated glomerular filtration rate percent change. The WI and CI groups maintained similar baseline function, which likely was a result of functional compensation by the normal contralateral kidney. Multivariate analysis showed increasing age and tumor size, and female gender as the only predictors of reduced long-term postoperative renal function. To minimize biases, various sensitivity analyses were conducted, none of which revealed differences between the CI and WI groups in renal function outcomes. Despite its multiple limitations, the present study, rather than discrediting CI, stresses the appropriateness of the intuitive choice between the 2 ischemia types and gives room for expanding the indications for CI, which can be a challenge in a time when most small renal tumors are operated on using minimally invasive techniques. M. Pilar Laguna, MD, PhD
Suggested Reading Weight CJ, Larson BT, Fergany AF et al: Nephrectomy induced chronic renal insufficiency is associated with increased risk of cardiovascular death and death from any cause in patients with localized cT1b renal masses. J Urol 2010; 183: 1317. Lane BR, Babineau DC, Poggio ED et al: Factors predicting renal functional outcome after partial nephrectomy. J Urol 2008; 180: 2363. Lane BR, Russo P, Uzzo RG et al: Comparison of cold and warm ischemia during partial nephrectomy in 660 solitary kidneys reveals predominant role of nonmodifiable factors in determining ultimate renal function. J Urol 2011; 185: 421. Thompson RH, Frank I, Lohse CM et al: The impact of ischemia time during open nephron sparing surgery on solitary kidneys: a multi-institutional study. J Urol 2007; 177: 471. Yossepowitch O, Eggener SE, Serio A et al: Temporary renal ischemia during nephron sparing surgery is associated with short-term but not long-term impairment in renal function. J Urol 2006; 176: 1339. Song C, Bang JK, Park HK et al: Factors influencing renal function reduction after partial nephrectomy. J Urol 2009; 181: 48.
Laparoscopy/New Technology Re: Salvage Surgery after Energy Ablation for Renal Masses J. A. Karam, C. G. Wood, Z. R. Compton, P. Rao, R. Vikram, K. Ahrar and S. F. Matin Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas BJU Int 2015; 115: 74e80.
SOCIOECONOMIC FACTORS, UROLOGICAL EPIDEMIOLOGY AND PRACTICE PATTERNS
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.05.008 available at http://jurology.com/ Editorial Comment: The authors report their single institution experience with salvage nephrectomy and partial nephrectomy for recurrent tumor after primary cryoablation or radiofrequency ablation. A total of 14 patients elected to undergo salvage surgery after initial treatment (14 percutaneous ablations, 1 laparoscopic ablation). Of the patients 11 underwent partial nephrectomy and 3 planned radical nephrectomy with 1 microscopic positive margin. There were more adverse events than one would expect if primary surgery were performed. However, the authors indicate that surgical salvage, especially when partial nephrectomy is planned, is technically achievable with acceptable morbidity. I would agree. Last decade many surgeons reported severe desmoplastic reactions encompassing the kidney after laparoscopic cryoablation such that nephrectomy was often inevitable. This outcome was likely due to the laparoscopic dissection and not the ablation itself. As in this study, it is my experience that after percutaneous ablation the desmoplastic reaction is focal such that subsequent partial nephrectomy, usually robotic, is feasible. Surgical salvage after prior percutaneous ablation should not be as intimidating as after prior laparoscopic ablation. Jeffrey A. Cadeddu, MD
Suggested Reading Nguyen CT, Lane BR, Kaouk JH et al: Surgical salvage of renal cell carcinoma recurrence after thermal ablative therapy. J Urol 2008; 180: 104.
Socioeconomic Factors, Urological Epidemiology and Practice Patterns Re: Robot-Assisted Surgery for Kidney Cancer Increased Access to a Procedure that can Reduce Mortality and Renal Failure A. Chandra, J. T. Snider, Y. Wu, A. Jena and D. P. Goldman John F. Kennedy School of Government, Harvard University and National Bureau of Economic Research, Cambridge, and Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, and Schaeffer Center for Health Policy and Economics, University of Southern California and Precision Health Economics, Los Angeles, California Health Aff (Millwood) 2015; 34: 220e228.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.05.025 available at http://jurology.com/ Editorial Comment: This analysis of the SEER (Surveillance, Epidemiology and End Results)Medicare data set compared partial nephrectomy rates in hospital referral regions that had robotic capabilities with those that did not. The authors report that partial nephrectomy rates were higher in regions that had robotic capabilities. They also compared rates of mortality and renal failure after radical and partial nephrectomy, and found that partial nephrectomy has better outcomes. I believe that one of these findings is true, despite a rather flawed analysis. Specifically while I believe that robotic surgery has made partial nephrectomy more attractive to patients (who previously might have opted for laparoscopic radical nephrectomy over open partial nephrectomy), I really doubt that partial nephrectomy is independently associated with superior 1-year mortality outcomes, as the study shows. These results are inconsistent with the urological literature and represent a case of inadequate risk adjustment. There may be differences with longer term followup but I find it unlikely that 1-year differences in mortality are due directly to the type of surgery performed, holding all of the factors constant. This issue underscores the importance of including clinicians with expertise in the disease topic on the research team. A team of outstanding economists may know a great deal about health care expenditures but they apparently do not know as much about the nuances of kidney cancer and urological surgery. David F. Penson, MD, MPH
333
332
Re: Impact of Warm versus Cold Ischemia on Renal Function following Partial Nephrectomy S. E. Eggener, M. A. Clark, S. Shikanov, B. Smith, M. Kaag, P. Russo, J. C. Wheat, J. S. Wolf, Jr., S. F. Matin, W. C. Huang, M. Harel, J. Cambio, A. L. Shalhav and J. D. Raman Section of Urology, University of Chicago, Chicago, Illinois World J Urol 2015; 33: 351e357.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.05.020 available at http://jurology.com/ Editorial Comment: This large multicenter study explores percent changes in estimated glomerular filtration rate in patients with a normal contralateral kidney treated with partial nephrectomy under warm (WI) or cold ischemia (CI). Because of the retrospective nature, differences between ischemia type groups were seen in baseline comorbidity, tumor size and renal function, reflecting intuitive surgeon choice. The second detail that captures attention is the higher percentage of CI cases in the whole population (63%) and in the open PN group (92%), likely reflecting practice at United States tertiary centers and the difficulties of applying CI during laparoscopic or robotic procedures. Lastly, albeit significantly, a discrete difference was observed in median ischemia time between groups. At long-term followup (3 to 18 months) neither WI nor CI time was significantly associated with estimated glomerular filtration rate percent change. The WI and CI groups maintained similar baseline function, which likely was a result of functional compensation by the normal contralateral kidney. Multivariate analysis showed increasing age and tumor size, and female gender as the only predictors of reduced long-term postoperative renal function. To minimize biases, various sensitivity analyses were conducted, none of which revealed differences between the CI and WI groups in renal function outcomes. Despite its multiple limitations, the present study, rather than discrediting CI, stresses the appropriateness of the intuitive choice between the 2 ischemia types and gives room for expanding the indications for CI, which can be a challenge in a time when most small renal tumors are operated on using minimally invasive techniques. M. Pilar Laguna, MD, PhD
Suggested Reading Weight CJ, Larson BT, Fergany AF et al: Nephrectomy induced chronic renal insufficiency is associated with increased risk of cardiovascular death and death from any cause in patients with localized cT1b renal masses. J Urol 2010; 183: 1317. Lane BR, Babineau DC, Poggio ED et al: Factors predicting renal functional outcome after partial nephrectomy. J Urol 2008; 180: 2363. Lane BR, Russo P, Uzzo RG et al: Comparison of cold and warm ischemia during partial nephrectomy in 660 solitary kidneys reveals predominant role of nonmodifiable factors in determining ultimate renal function. J Urol 2011; 185: 421. Thompson RH, Frank I, Lohse CM et al: The impact of ischemia time during open nephron sparing surgery on solitary kidneys: a multi-institutional study. J Urol 2007; 177: 471. Yossepowitch O, Eggener SE, Serio A et al: Temporary renal ischemia during nephron sparing surgery is associated with short-term but not long-term impairment in renal function. J Urol 2006; 176: 1339. Song C, Bang JK, Park HK et al: Factors influencing renal function reduction after partial nephrectomy. J Urol 2009; 181: 48.
Laparoscopy/New Technology Re: Salvage Surgery after Energy Ablation for Renal Masses J. A. Karam, C. G. Wood, Z. R. Compton, P. Rao, R. Vikram, K. Ahrar and S. F. Matin Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas BJU Int 2015; 115: 74e80.
SOCIOECONOMIC FACTORS, UROLOGICAL EPIDEMIOLOGY AND PRACTICE PATTERNS
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.05.008 available at http://jurology.com/ Editorial Comment: The authors report their single institution experience with salvage nephrectomy and partial nephrectomy for recurrent tumor after primary cryoablation or radiofrequency ablation. A total of 14 patients elected to undergo salvage surgery after initial treatment (14 percutaneous ablations, 1 laparoscopic ablation). Of the patients 11 underwent partial nephrectomy and 3 planned radical nephrectomy with 1 microscopic positive margin. There were more adverse events than one would expect if primary surgery were performed. However, the authors indicate that surgical salvage, especially when partial nephrectomy is planned, is technically achievable with acceptable morbidity. I would agree. Last decade many surgeons reported severe desmoplastic reactions encompassing the kidney after laparoscopic cryoablation such that nephrectomy was often inevitable. This outcome was likely due to the laparoscopic dissection and not the ablation itself. As in this study, it is my experience that after percutaneous ablation the desmoplastic reaction is focal such that subsequent partial nephrectomy, usually robotic, is feasible. Surgical salvage after prior percutaneous ablation should not be as intimidating as after prior laparoscopic ablation. Jeffrey A. Cadeddu, MD
Suggested Reading Nguyen CT, Lane BR, Kaouk JH et al: Surgical salvage of renal cell carcinoma recurrence after thermal ablative therapy. J Urol 2008; 180: 104.
Socioeconomic Factors, Urological Epidemiology and Practice Patterns Re: Robot-Assisted Surgery for Kidney Cancer Increased Access to a Procedure that can Reduce Mortality and Renal Failure A. Chandra, J. T. Snider, Y. Wu, A. Jena and D. P. Goldman John F. Kennedy School of Government, Harvard University and National Bureau of Economic Research, Cambridge, and Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, and Schaeffer Center for Health Policy and Economics, University of Southern California and Precision Health Economics, Los Angeles, California Health Aff (Millwood) 2015; 34: 220e228.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.05.025 available at http://jurology.com/ Editorial Comment: This analysis of the SEER (Surveillance, Epidemiology and End Results)Medicare data set compared partial nephrectomy rates in hospital referral regions that had robotic capabilities with those that did not. The authors report that partial nephrectomy rates were higher in regions that had robotic capabilities. They also compared rates of mortality and renal failure after radical and partial nephrectomy, and found that partial nephrectomy has better outcomes. I believe that one of these findings is true, despite a rather flawed analysis. Specifically while I believe that robotic surgery has made partial nephrectomy more attractive to patients (who previously might have opted for laparoscopic radical nephrectomy over open partial nephrectomy), I really doubt that partial nephrectomy is independently associated with superior 1-year mortality outcomes, as the study shows. These results are inconsistent with the urological literature and represent a case of inadequate risk adjustment. There may be differences with longer term followup but I find it unlikely that 1-year differences in mortality are due directly to the type of surgery performed, holding all of the factors constant. This issue underscores the importance of including clinicians with expertise in the disease topic on the research team. A team of outstanding economists may know a great deal about health care expenditures but they apparently do not know as much about the nuances of kidney cancer and urological surgery. David F. Penson, MD, MPH
333